Provider Demographics
NPI:1083987143
Name:NICHOLSON, JESSI ELIZABETH (LAC MOM)
Entity Type:Individual
Prefix:
First Name:JESSI
Middle Name:ELIZABETH
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LAC MOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:GRAND MARAIS
Mailing Address - State:MN
Mailing Address - Zip Code:55604
Mailing Address - Country:US
Mailing Address - Phone:218-370-8378
Mailing Address - Fax:218-387-3584
Practice Address - Street 1:101 W HWY 61
Practice Address - Street 2:SUITE 130
Practice Address - City:GRAND MARAIS
Practice Address - State:MN
Practice Address - Zip Code:55604
Practice Address - Country:US
Practice Address - Phone:218-370-8378
Practice Address - Fax:218-387-3584
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1451171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist